Iranian nurses’ understanding of moral distress in pediatric wards

doi:10.21203/rs.3.rs-4615952/v1

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Research Article

Iranian nurses’ understanding of moral distress in pediatric wards

https://doi.org/10.21203/rs.3.rs-4615952/v1

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Background: As direct and continuous providers of patient services, nurses are more exposed tovarious types of psychological stress in the work environment compared to other members of the health system. Nurses working in pediatric wards are in contact with children, and their families are more exposed to moral distress.This study aimed to investigate Iranian nurses’ understanding of moral distress in pediatric wards.

Methods: This qualitative study was conducted through inductive content analysis in 2023-2024. Data were collected through semi-structured and individual interviews and analyzed simultaneously and continuously using Graneheim and Lundman’s approach.

Twelve participants among nurses with moral distress experiences were selected through purposive sampling from Babol and Tehran Universities of Medical Sciences.

Results: The study findings include four main classes and eight subclasses: 1) moral distress related to colleagues (doctor and nurse colleagues), 2) moral distress related to parents (conflict with children’s rights and distrust in nurses), 3) moral distress related to organizational factors (lack of manpower and proper equipment), and 4) psychological tensions following moral distress (mental conflict and exhaustion).

Conclusion: The findings demonstrate the need for mechanisms by managers and officials to hold educational programs and workshops to help reduce moral distress levels in nurses. To this end, it is necessary to identify the stressful conditions caused by nursing care in this ward and reduce nurses’ exposure to stress in moral dilemmas.

Nurse

Distress

Ethics

Children

According to Jamton (1984), moral uncertainty, moral dilemmas, and moral distress are three ethics-related problems experienced by a nurse in a clinical setting. Moral distress arises when “someone knows they are doing the right thing, but organizational constraints make it almost impossible to follow through” (1). Although this definition limits the concept of moral distress to the nursing population, several studies indicate that moral distress can encompass all care professionals in healthcare settings. Due to the extent of this concept, moral distress can be experienced as a response to any moral conflict (2).

Research on moral distress in healthcare systems and its consequences on healthcare professionals has increased recently. Such studies classify moral distress into three categories at the patient, unit, and system levels (3–5). Therefore, moral disturbance of events is found in all wards or health centers (6–9).

Nurses are more exposed to ethical decision-making in the care and treatment of patients in some special departments due to the presence of intense physical and psychophysical work pressure. In this respect, nurses’ exposure to these stressful conditions increases their levels of moral distress (10).

Since pediatric nurses directly communicate with patients and their parents, their care requires the presence of nurses with pertinent scientific and moral qualifications (11). In general, ethical care of children includes the responsibility of achieving the highest knowledge level, considering the child’s physical, mental, and social development, reliable communication and empathy with the child and parents, compliance with the recommendations of the United Nations Convention on the Rights of the Child (UNCRC) at hospitals, and cooperation with professionals of related professions (12). According to a Swedish study, less than a third of pediatric nurses had a positive understanding of possible good ethical care (13). Other studies have proposed a correlation between ethical decision-making and such factors as job satisfaction and moral distress (14).

According to the American Nurses Association, nurses employ an advanced systematic process in dealing with children and their families when returning to potentially critical situations (15). Therefore, they are in contact with children and their families and are more exposed to moral distress (16, 17). Caring for diseased children exposes nurses to multiple ethical challenges. Despite good intentions to provide good ethical care, personal and professional ethical values are challenged in clinical practice. This issue is more noticed when pediatric nurses use treatment methods that are unpleasant and painful or when parents do not tell the truth (18). Moral distress is a phenomenon that can influence nurses, patients, and health systems differently and can lead to detrimental consequences. This phenomenon can pose a conflict in patient care, preventing the nurse from confronting the patient and providing quality care (19). This condition leads to defects in the healing process and prolongs hospitalization time (20). In addition to the mentioned issues, continued moral distress can cause emotional reactions such as anger, despair, guilt, and physical disorders such as headaches and sleep disorders in nurses (21). Moral distress can affect nurses’ sense toward their abilities and initiative. The literature indicates that 81% of nurses in intensive care wards described themselves as powerless and ineffective due to moral tension (22). Nurses experience discomfort and anxiety when they deal with situations that are beyond their control and cannot do the right task for their patients (13).

The characteristics of pediatric wards and the organizational relationships governing these wards are different in different hospitals. Furthermore, the individual characteristics, theoretical-practical knowledge, and scientific experiences of nurses working in these wards can probably affect their quality of care. There are scarce studies concerning decision-making patterns and moral distress in pediatric hospitals in Iran. In this respect, most studies focus on pediatric intensive care wards (13, 15, 19) governed by different clinical decision-making patterns. Besides, most previous studies have been conducted quantitatively and with different tools, and no Iranian study has investigated nurses’ experiences of moral distress with a qualitative method. The current research aims to elaborate on pediatric nurses’ experiences of moral distress through the content analysis approach.

Design

A qualitative approach with the content analysis method was chosen to achieve the goal of this study. Qualitative research allows access to participants’ experiences in the natural arena and is useful for studying less-investigated phenomena (23).

Participants and research context

In this study, the participants were sampled purposively among those working in pediatric wards who experienced moral distress. Nurses were selected from different genders and different wards and hospitals to provide rich, wide, and deep data with a sampling strategy with maximum diversity (Table 1). The sample size was determined based on data saturation so that data were collected to a stage where the continued data collection was the repetition of the previous data without obtaining new data (24). In this research, data were collected through semi-structured individual interviews. The data collection process started with the participants filling out consent forms. The interview was the main data collection method in this research. It began with general and open questions such as “Please describe your experiences in a work shift in the pediatric ward”, “What have you experienced with ethical issues that you have faced while caring for a child”? and “What factors caused your moral distress while caring for a child?” Then, the interview process was directed toward achieving the research goals based on the stated content and asking leading and clarifying questions such as “Please explain more? or What do you mean?” In this method, respondents are free to extend their answers as long as they want, providing more depth and details, and the interview produces the richest data (25). Interviews were conducted with 12 nurses, and data saturation was obtained from 10 interviews. The interviews lasted 40 to 60 minutes. The interviews were recorded and immediately transcribed verbatim. The interviews were done individually in a quiet environment at the participants’ workplaces (23).

Table 1

Profiles of the participants
Hospital		Ward				Education		Marital status		Gender
Tehran	Babol	Oncology	Infectious	Surgery	Emergency	MSc	BSc	Single	Married	F	M
8	4	2	2	3	5	2	10	2	10	8	4

Analysis of data

The collected data were analyzed data using Graneheim and Lundman’s approach (2004). The researcher transcribed each interview and listened to it several times to obtain a general mindset and familiarity with the text. Then, semantic units in the text were identified, and appropriate codes were extracted from them. Through repetition of interviews, the extracted codes were compared based on differences and similarities and assigned to abstract classes with specific labels. Finally, the classes were compared with the subclasses and placed in appropriate themes, with careful and deep reflection on them and the text of related data (26).

Data reliability considerations

Several criteria have been stated for data evaluation and reliability in qualitative research. Based on the criteria proposed by Corbin and Strauss (2008), we tried to maintain the findings tailored to the subjects’ experiences by reviewing them with the participants and research team members, thereby reaching confidence in the obtained results. The research findings can be practical by providing new insight, adding to nurses’ knowledge level, and changing nurses’ attitudes and performance. With organized concepts and themes, the findings provide the ground for understanding and professional development in nursing. The researcher tried to maintain a logical way of expressing the findings and not confuse the reader. Concepts with an organized structure have the necessary depth by describing the details and finding the common language of the subjects in terms of pediatric nurses’ experiences of moral distress. Data were collected from samples with diverse characteristics and in different locations to determine the generalizability of the results. The findings were presented creatively and innovatively in terms of pediatric nurses’ experiences of moral distress to raise a new issue in the current research. The researcher tried to be sensitive to the participants and the obtained data and to extract the questions from the data analysis without including personal opinions.

Moreover, the comparative analysis process was continuously done throughout the data collection process to validate the data further. The verifiability was improved by reviewing the participants' findings. The obtained results were verified by asking experts outside the research team to assess the compatibility of the findings with the pediatric nurses’ experiences of moral distress (27).

Ethical considerations

The research started after the approval (with the code IR.IAU.BABOL.REC.1402.115) of the ethics committee of the Islamic Azad University, Babol Branch. Before starting the interview sessions, the participants were given necessary information about the study and its goal. The participants agreed to cooperate, and the interview time and place were agreed upon. The interview sessions were recorded after obtaining the participant’s consent. The researcher stopped recording the interview at any time requested by the participants. The participants were also ensured of their right to withdraw the research freely. Upon the participants’ request, the results were presented to them by observing the confidentiality of names.

The data analysis results from the pediatric nurse’s experiences of moral distress include 530 primary codes, 4 classes, and 8 subclasses (Table 2).

Table 2

Primary classes and subclasses of data analysis for concepts
Classes	Subclasses
Moral distress related to colleagues	Moral distress related to doctor colleagues
Moral distress related to colleagues	Moral distress related to nursing colleagues
Moral distress related to parents	Conflict with children’s rights
Moral distress related to parents	Distrust in the nurse
Moral distress related to organizational factors	Shortage of manpower
Moral distress related to organizational factors	Lack of suitable equipment
Psychological tensions following moral distress	Mental conflict
Psychological tensions following moral distress	Exhaustion

1. Moral distress related to colleagues

A perceived theme of pediatric nurses is “moral distress related to colleagues”. Nurses experience moral distress due to the insufficient skills of some doctors, the possibility of harming the patient, and the irresponsibility of some nursing colleagues. This moral distress was classified into the dimensions of moral distress related to doctors and that related to nursing colleagues.

• Moral distress related to doctors is among the dimensions of the moral distress concept related to colleagues. This theme indicates that most participants experienced moral distress after doing unethical work by doctors and insufficient skills in doing the work. Some participants stated that they felt weak and like robots with doctors following the unethical work by doctors and obeying them without any question. They were insulted by the doctors due to the provision of correct information and education to the parents about the disease and the drugs.

In this regard, a participant stated: “I was in a private hospital. I had just entered the ward. I opened the Cardex and told the mother that your child would be only given PediLact. The mother was angry and told me that she paid 5 million Tomans only per night for a hotel... The doctor pulled me aside and said: “You had no right to give medical information to the mother. Who do you think you are?” (M8).

The participants expressed that some doctors were not skilled enough to perform work in emergencies, and this caused loss or damage to the patient. The nurses considered the doctor’s refusal to accept the nurse’s words and their work assignment to another colleague, among other cases that caused moral distress in pediatric wards.

In this respect, a participant uttered: “Sometimes when an unskilled doctor wants to intubate but he/she cannot. I say to them not to do this because they are harming the patient. He/she does not want to accept it because they are a doctor and we’re nurses... We had a case where the doctor could not intubate, and the patient expired because of emphysema. I still see the child’s face in my eyes.....This is moral distress” (M9).

• Moral distress related to nurse colleagues: Another dimension of the moral distress concept is related to colleagues, showing that nurses experience moral distress due to irresponsibility, insufficient skills in doing the work, and insistence on doing it by some colleagues. The participants claimed that the nurses misbehaved with the child due to work fatigue and did not entrust the work to their colleagues in such a situation, which could increase the possibility of errors.

The nurses mentioned inattention to the child’s privacy and confidentiality by the treatment team as one of the ethical issues and challenges in pediatric wards. They stated that no attention is paid to such a situation, where the child’s privacy should be considered. They expected the remaining information about their children to be confidential.

A participant’s experiences confirm this: “A child was in the emergency room for two hours due to sexual abuse. In the end, he/she complained about why everyone was allowed to check me. The child’s privacy was broken... but no one cared about this. I was so shocked, and I couldn’t say even a word. Everyone was talking to each other about this child... everyone was looking” (M6).

Nurses considered the insistence of senior colleagues for the child venipuncture despite being tired, followed by aggressiveness with the child and misbehavior, among other cases of moral distress. They stated that some experienced colleagues do not allow newcomer personnel to work. Meanwhile, the fatigue caused by repeated and useless efforts to do work could increase the possibility of mistakes and psychophysical harm to the child.

In this regard, a participant mentioned: “Some colleagues seem to have to do venipuncture by themselves... Those with a long work experience have tried more than 10 times. We advise them, but they don’t listen to us. I witnessed my colleague irritated, pushed, or pressed the child’s head because of fatigue... or even once the Angiocath came out of the skin, but my colleague did not let me do the child venipuncture” (M8).

2. Moral distress related to parents

The moral distress concept related to patients’ companions indicates that the participants experience moral distress concerning the presence of companions at the patient’s bed during venipuncture, medication, and interference with their work. The concept features include conflict with the child’s rights and distrust in the nurse.

• The concept of conflict with children’s rights denotes that the participants consider the families’ low information in some areas, failure to visit the hospital timely, and the death of the child as the causes of the nurses’ moral tensions. In this regard, they claimed that some families disregarded the child’s symptoms and sometimes used incorrect methods to calm the child. In dealing with such cases, nurses were so stressed that they could not take proper action.

For instance, a participant uttered: “We had a case that a family had given opium to a baby that cried a lot to calm him down... A 9-year-old child who had a drop in the consciousness level. I told them you should not do this, and they said that they always did this.... the child was sent. After that, I would cry upon visiting any child’s bed to the end of the shift, I would feel helpless” (M6).

The nurses stated that sometimes families’ inattention to the child and carelessness could lead to the death of the child. Sometimes, families seek their work for hours without knowing about the child, which can lead to irreparable consequences. Nurses are affected by facing such conditions and suffer moral distress.

A participant stated: “I visited a sick child whose family was engaged in a food charity ceremony, not knowing about their child for several hours. The 2-year-old child fell from the fence at the neighbor’s house and got a concussion... It affected me a lot. I felt internal stress... I didn’t know what I should do at that moment. He/she would have been saved if the family had brought him/her earlier” (M7).

• Nurses considered the presence of companions in the ward, distrust in nurses, and their inappropriate requests against the doctor’s orders out of ignorance as the causes of moral tension in the ward. They asserted that mothers regularly visited the nursing station and asked for painkillers or temperature measures and paid excessive attention to the child, resulting in nurses’ confusion and moral tension.

In this respect, a participant expressed: “I had a patient with a fever of 38.5℃. The doctor had ordered me not to give painkillers, but the companions were at the station all the time... They expect you always to visit them or give drugs wilfully. These things are very stressful” (M5).

The interviewees believed that the presence of mothers during a child’s venipuncture interfering with their work, constantly hugging the children, and damaging their veins despite the nurses’ warnings were the causes of moral tensions.

For example, a participant mentions: “Upon venipuncture, mom is standing on top of you, and you feel stress like this... they always want to step in, like how much blood you get when you pierce the child... don’t touch my child. If you say something, they will complain to the head of the hospital” (M2).

The nurses considered the patient companions’ distrust in the nurse to send the child to the operating room (OR), the constant request from the nurse to send their child to the OR earlier, and the negative attitude toward the nurses in breaking their appointments as cases of moral distress.

“The patient goes to the OR according to the priority, the doctor calls him/herself, and the mother comes regularly and says my child should go first; whatever you say is useless.... They think it’s a partiality” (M5).

3. Moral distress related to organizational factors

The moral distress concept related to organizational factors suggests that some management factors and organizational policies can cause moral distress in nurses. Nurses mentioned the high workload, understaffing, and lack of suitable and sufficient equipment as the factors of moral distress.

• Understaffing is a dimension of the moral distress concept related to organizational factors, showing that time shortage and high workload do not allow for doing some tasks, causing moral distress in nurses. The participants think that they cannot pay attention to the psychological conditions of children and families due to the high workload and the undermanning. They blame themselves and feel guilty for neglecting their parents’ ignorance and stress.

In this respect, a participant states: “They don’t observe professional ethics...the child or their family’s mental state is not taken into account...this is because of the high workload or too much fatigue...I somehow feel guilty about it. I tell the child’s family, who is worried, stay behind the door, don’t talk at all... it bothers me” (M10).

Nurses considered the shortages of nurses and the high number of patients, thereby increasing the possibility of medication errors in the ward. They believe that the possibility of medication error increases unconsciously with the workload increase. This issue poses them to stress psychologically, leading to a sense of ineffectiveness and incompetence.

“I made a mistake once; I took 10 mg of vitamin K instead of 1 mg... I was busy and distracted... I felt guilty for a long time. I felt unworthy” (M12).

• The lack of suitable equipment is another dimension of the moral distress concept related to organizational factors. This concept means that faulty devices and equipment in the ward, insufficient explanations about working with a new device by the relevant official, and the deficiency of required drugs cause moral distress in nurses.

For instance, a participant uttered: “They call from other wards if you have this serum or medicine. Because I know I have no support, I unwantedly say no. I have to prioritize the needs of my ward... but then I feel betrayed as I lied” (M11).

4. Psychological tensions following moral distress

This concept indicates that nurses experience feelings of guilt, humiliation, helplessness, and despair because of moral distress. Mental involvement and exhaustion are the major features of this concept.

• Mental conflict is a dimension of the psychological tension concept. This concept shows the engagement of nurses’ minds and their stress when they suffer moral distress due to parents’ ignorance and inattention to their children.

In this respect, a participant stated: “The child falling through the fence and the parents’ negligence affected me a lot... I shielded the fence of the house... I was so worried that I told everyone what happened... I got inner stress. I was thinking about it for a long time” (M7).

The nurses believed that the insistence of some colleagues to do tasks despite their tiredness induced mental conflict in them. The participants stated that quarrels among colleagues for failure to examine the child’s vein caused the nurse’s anger and mental conflict, thereby increasing the possibility of child injury.

• Exhaustion is another dimension of the psychological tension concept following moral distress. The participants expressed feeling helpless and desperate upon facing situations such as wrongdoing by colleagues regarding medication procedures and inattention to their words.

In this regard, a participant stated: “I often saw colleagues doing something wrong, for example, about using medicines... I said, but they did not care about it. I felt desperate and helpless when no one heard my voice. No one listened to me, and I didn’t care about it. I read and studied all this, but it didn’t help” (M11).

Nurses felt guilty and inefficient when facing the sudden death of a newborn. They expressed: “When the baby suddenly showed apnea while being monitored, and everything was fine, I felt sick. I prefer to take a few days off to be away from the ward. I knew myself the cause of the child’s death.

This study has tried to achieve a deeper and richer insight into pediatric nurses’ experiences of moral distress through a qualitative study aiming at discovering and explaining this phenomenon. The nurses in this study reported that they experienced moral distress because of their colleagues, parents, and the organization. They considered these factors involved in the moral distress occurrence in pediatric wards. Likewise, the results of a systematic review confirm that there are many moral distress triggers related to factors at the patient, unit/team level, or causes at the system level, as reported in previous studies (4, 28–30). Overall, the causes of moral distress are different and can be classified as factors related to patients, the organization, intergroup relations, and treatment methods (31).

The first theme extracted from the interviews was moral distress related to colleagues. The insufficient skills of some doctors and nurse colleagues in doing their tasks and forcing nurses to be silent and obey doctors were among the factors that caused moral distress in the nurses. Similarly, evidence indicates that moral distress is often related to factors at the unit/team and system levels. Poor communication within the unit or insufficient cooperation between team members can cause moral distress. In addition, the feeling of insecurity or ineffectiveness perceived by employees is a cause of moral distress (1). Papathanassoglou et al. (2012) reported a negative relationship between moral distress scores and nurse-doctor cooperation (32). Absolute obedience to orders from superordinate people, lack of professional independence, and inability to modify care methods can be regarded as the causes of intergroup relations (33). In this respect, the findings of a systematic review reveal a positive correlation between nurses’ professional independence (34), empowerment (35), and moral distress scores. Additionally, nurses who feel supported by supervisors experienced less moral distress (36).

The second theme obtained was the concept of moral distress related to parents. The participants believed that the presence of companions in the ward and interference in their work were among the causes of moral distress. Various studies have reported that nurses who work in pediatric wards and are in contact with children and their families are more exposed to moral distress (11, 17). Nurses experience a high level of moral distress when they practice painful treatment care, and families feel the need to exhaust their emotions and aggression (13). Young believes that painful and useless care, denial of prognosis, false hopes, and expectations of families are the most common causes of moral distress (37).

Moral distress related to organizational factors was another theme extracted in this study. Shortage of nurses, high workload, and insufficient time allocation to support the patient led to nurses’ moral distress. The results of some other studies are in line with these results. Nurses’ time shortage, inadequate staff levels, heavy workloads, and busy work shifts (38) have caused concern among pediatric oncology nurses, as their time shortage prevented their family support in such a way that they felt it (39). Accordingly, the lack of compassionate and high-quality care caused moral distress among pediatric oncology nurses (40). Reviewing the literature reveals that promoting academics and retaining skilled nurses can help produce a positive moral atmosphere. However, medical and nursing knowledge and skills must be updated constantly. Hence, continuous learning activities are necessary to raise nurses’ professional growth. Research has shown that the pressure imposed on nurses by organizations and institutional policies, working with incompetent colleagues, poor management, high workload, and shortage of facilities and manpower are among the factors affecting moral distress development (41).

The concept of psychological tensions following moral distress denotes that nurses experience tensions in the form of mental conflicts resulting from their problems with their families and colleagues. According to Forozeiya et al., when nurses in contact with patients, families, and colleagues encounter morally distressing situations, they choose a solution to escape from that situation. Among these strategies are the intention to leave the profession, absenteeism at work, or staying away from family members (42).

Despite rich studies on this topic, moral distress as a problem in clinical departments is still associated with the increased risks of leaving the profession, burnout for healthcare professionals, and negative consequences for doctors (9, 43, 44). Ignoring the causes of moral distress results in negative consequences such as moving nurses within the wards, leaving the profession, withdrawing from patients, reducing communication with other members of the treatment team, reducing organizational support, and fear of legal consequences (45–48), job dissatisfaction, and decreasing patient care safety and quality (11, 49, 50). Some studies have reported negative effects of moral distress on nurses’ physical health in the form of nightmares, insomnia, heart palpitations, neck pain, a sense of worthlessness, anger, depression, shame, and discomfort in their professional lives (46, 51, 52). These findings are consistent with our study, wherein nurses felt helpless due to moral distress in the pediatric ward and preferred to be away from the ward and patient care for a while.

According to the present findings, nurses influenced by moral distress in the pediatric ward will feel uncomfortable and annoyed. If repeated, this issue will disrupt their adaptability, self-esteem, and ability to provide care. In such a situation, they may adopt negative compliance methods that affect the quality of patient care and cause secondary complications. Therefore, nurses should be encouraged to express their feelings to establish a balance between the difficulty of ethical decisions, meeting the patient’s needs, and managing their emotions. It is also necessary to mitigate moral distress and promote systematic and interpretive clinical decision-making among nurses. This objective can be achieved by boosting knowledge, clinical experiences, self-belief, and self-confidence, organizational supports such as encouraging nursing managers to participate in clinical decision-making, establishing an effective relationship with the doctor, using nurses’ experiences and clinical skills in medical diagnoses and patient care, inter-team cooperation in clinical challenges, reducing nurses’ workload, and creating the opportunity to use information resources. Furthermore, it seems necessary to design and organize educational programs and workshops to help reduce nurses’ level of distress. To this end, it is necessary to identify the stressful conditions caused by nursing care in this ward and reduce nurses’ level of exposure to moral dilemmas by considering individual-social and professional factors affecting them.

Since the present research was a qualitative study with few participants, data should be interpreted cautiously. Due to the lack of appropriate tools to evaluate moral distress in the pediatric ward in Iran, it is proposed to study the design of moral distress tools in this ward.

UNCRC: United Nations Convention on the Rights of the Child

Acknowledgments

The authors would like to thank the deputy of research of Islamic Azad University, Babol Branch for supporting them in this study, and thank all the nurses who cooperated in the project

Authors’ contributions

F.S.N.R. and M.N. undertook the data collection. N.R. data analysis and wrote the manuscript. N.R. and H.A. supervised the analysis and research process. All the authors read and approved the final manuscript.

Funding statement

This research received no specific grant from any funding agency in the public, or commercial

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to [individual privacy could be compromised] but are available from the corresponding author on reasonable request.

Ethical approval and informed consent statements

The research started after the approval (with the code IR.IAU.BABOL.REC.1402.115) of the ethics committee of the Islamic Azad University, Babol Branch. Before starting the interview sessions, the participants were given necessary information about the study and its goal. Since all participants were over 16 years old, an informed consent letter was obtained from all the participants before the start of the study. All methods were carried out by relevant guidelines and regulations in the Ethical Declarations.

Declaration of conflicting interest

No conflict of interest has been declared by the authors

Consent for publication

Not Applicable.

Author Details

^1,3Department of Nursing and Midwifery, Comprehensive Health Research Center, Babol Branch, Islamic Azad University, Iran.²Assistant Professor, Department of Nursing, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran. ⁴Disaster Management and Medical Emergency Center, Mazandaran University of Medical Sciences, Sari, Iran.

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No competing interests reported.

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Iranian nurses’ understanding of moral distress in pediatric wards

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Abstract

Background

Methods

Design

Participants and research context

Analysis of data

Data reliability considerations

Ethical considerations

Results

1. Moral distress related to colleagues

2. Moral distress related to parents

3. Moral distress related to organizational factors

4. Psychological tensions following moral distress

Discussion and conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1